Healthcare Provider Details

I. General information

NPI: 1184957771
Provider Name (Legal Business Name): SOUTH COUNTY COMMUNITY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1807 BAY ROAD
EAST PALO ALTO CA
94303-1312
US

IV. Provider business mailing address

1885 BAY RD
EAST PALO ALTO CA
94303-1312
US

V. Phone/Fax

Practice location:
  • Phone: 650-330-7407
  • Fax: 650-321-1560
Mailing address:
  • Phone: 650-330-7410
  • Fax: 650-321-1156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberAPPLIED FOR
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberAPPLIED FOR
License Number StateCA

VIII. Authorized Official

Name: MS. LUISA M. BUADA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: RN, MPH
Phone: 650-330-7410